Lymph Nodes

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Chapter 18 Lymph Nodes

A. General Considerations

Lymph nodes are important. A methodical search may yield invaluable clues in cancer or systemic disease. Some “sentinel” nodes have even entered medical folklore, forever linked by eponyms to the physicians who first described them.

8 What is the differential diagnosis of a generalizedadenopathy?

One of three processes: (1) a disseminated malignancy, especially hematologic (lymphomas, leukemias, and angioimmunoblastic lymphadenopathy); (2) a collagen vascular disorder (sarcoidosis, rheumatoid arthritis (RA), and systemic lupus erythematosus [SLE]); or (3) an infectious process (mononucleosis, cytomegalovirus [CMV], AIDS, toxoplasmosis, syphilis, tuberculosis, histoplasmosis, coccidioidomycosis, brucellosis, and bubonic plague). Drug reaction can do it, too, and so can intravenous abuse. Some medications (e.g., phenytoin) specifically cause lymphadenopathy; others (e.g., cephalosporins, penicillins, or sulfonamides) do it instead in the context of a serum sickness-like syndrome, with fever, arthralgias, and skin rash (see Table 18-1).

Table 18-1 Medications That May Cause Lymphadenopathy

Allopurinol (Zyloprim) Penicillin
Atenolol (Tenormin) Phenytoin (Dilantin)
Captopril (Capozide) Primidone (Mysoline)
Carbamazepine (Tegretol) Pyrimethamine (Daraprim)
Cephalosporins Quinidine
Gold Sulfonamides
Hydralazine (Apresoline) Sulindac (Clinoril)

(Adapted from Ferrer R: Lymphadenopathy. Am Fam Physician 58:1313–1323, 1998.)

12 Should one know the regions drained by the various lymphonodal stations?

Yes, since this may unlock the underlying cause. After detecting an enlarged node, always examine the region drained by it (see Table 18-2). Look for infections, skin lesions, or tumors.

Table 18-2 Lymph Node Groups: Location, Lymphatic Drainage and Selected Differential Diagnosis*

Location Lymphatic Drainage Causes
Submental Lower lip, anterior floor of mouth, tip of tongue, skin of cheek, teeth, nose Mononucleosis-like syndromes, Epstein-Barr virus, CMV, toxoplasmosis
Submandibular Tongue, submaxillary gland, lips and mouth, conjunctivae Infections of head, neck, sinuses, ears, eyes, scalp, pharynx
Anterior cervical (jugular) Tongue, tonsil, pinna, parotid, larynx, thryroid, upper esophagus Pharyngitis organisms, rubella, upper respiratory infections, cancer of tongue, larynx, thyroid and cervical esophagus
Posterior cervical Scalp and neck, middle ear, skin of arms and pectorals, thorax, cervical and axillary nodes Mononucleosis, toxoplasmosis, tuberculosis, rubella, otitis media, scalp infections and dandruff, Kikuchi’s disease, lymphoma, head and neck malignancy
Preauricular Eyelids and conjunctivae, temporal region, pinna Disease external auditory canal, ipsilateral conjunctivitis (Parinaud’s syndrome), lymphoma
Postauricular External auditory meatus, pinna, scalp Local infection, but also rubella
Occipital Scalp and head Local infection
Right supraclavicular node Breast, lungs, esophagus mediastinum, Lung, breast, mediastinum
Left supraclavicular node Breast, lungs, abdomen via thoracic duct, and pelvis Lymphoma, thoracic, retroperitoneal, gastrointestinal or pelvic cancer, bacterial or fungal infection
Axillary Arm, thoracic wall, breast Arm infections, cat-scratch disease, tularemia, lymphoma, breast cancer, silicone implants, brucellosis, melanoma
Epitrochlear Ulnar aspect of forearm and hand Infections, lymphoma, sarcoidosis and connective tissue diseases, tularemia, secondary syphilis, leprosy, leishmaniasis, rubella
Inguinal Penis, scrotum, vulva, vagina, perineum, gluteal region, lower abdominal wall, lower anal canal, extremities (benign reactive in shoeless walkers) Infections of the leg or foot, STDs (e.g., herpes simplex virus, gonococcal infection, syphilis, chancroid, granuloma inguinale, lymphogranuloma venereum), lymphoma, pelvic malignancy, bubonic plague

STDs = sexually transmitted diseases.

* Modified from Ferrer R: Lymphadenopathy. Am Fam Physician 58:1313–1323, 1998.

15 What about associated signs and symptoms?

They can be “local” or systemic (Table 18-4). Local findings suggest infection or neoplasm in a specific site (like the swollen nodes and lymphangitic streaks of a skin infection). Conversely, systemic symptoms (such as fever, fatigue, night sweats, and unexplained weight loss) argue in favor of a collagen vascular, lymphoproliferative, or infectious disorder (e.g., tuberculosis [TB]). Still, lack of associated signs or symptoms does not exclude malignancy and thus should not stop a work-up. Finally, remember that the adenopathy of Hodgkin’s disease may become painful after alcohol ingestion.

Table 18-4 Lymphadenopathy—Associated Signs and Symptoms

Disorder Associated Findings
Common Causes of Lymphadenopathy
Mononucleosis-type syndromes Fatigue, malaise, fever, atypical lymphocytosis
Epstein-Barr virus* Splenomegaly in 50%
Toxoplasmosis* 80–90% asymptomatic
Cytomegalovirus* Often mild symptoms; patients may have hepatitis
Initial stages of HIV infection* “Flu-like” illness, rash
Cat-scratch disease Fever in 30%; cervical or axillary nodes
Pharyngitis (group A Streptococcus, gonococcus) Fever, pharyngeal exudates, cervical nodes
Tuberculosis lymphadenitis* Painless, matted cervical nodes
Secondary syphilis* Rash
Hepatitis B* Fever, nausea, vomiting, icterus
Lymphogranuloma venereum Tender, matted inguinal nodes
Chancroid Painful ulcer, painful inguinal nodes
Lupus erythematosus* Arthritis, rash, serositis; renal, neurologic, hematologic disorders
Rheumatoid arthritis* Arthritis
Lymphoma* Fever, night sweats, weight loss in 20–30%
Leukemia* Blood dyscrasias, bruising
Serum sickness* Fever, malaise, arthralgia, urticaria; exposure to antisera or medications
Sarcoidosis Hilar nodes, skin lesions, dyspnea
Kawasaki disease* Fever, conjunctivitis, rash, mucosal lesions
Less Common Causes of Lymphadenopathy
Lyme disease* Rash, arthritis
Measles* Fever, conjunctivitis, rash, cough
Rubella* Rash
Tularemia* Fever, ulcer at inoculation site
Brucellosis* Fever, sweats, malaise
Plague Febrile, acutely ill with cluster of tender nodes
Typhoid fever* Fever, chills, headache, abdominal complaints
Still’s disease* Fever, rash, arthritis
Dermatomyositis* Proximal weakness, skin changes
Amyloidosis* Fatigue, weight loss

* Causes of generalized lymphadenopathy.

(Adapted from Ferrer R: Lymphadenopathy. Am Fam Physician 58:1313–1323, 1998.)

16 What about splenomegaly?

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